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Press Release
VA Researchers Say Better Doctor Training and Increased Focus on Patient Needs Required in End-of-Life Conversations
For immediate release September 26, 2000
CHICAGO – Dying and end-of-life issues care issues have been the focus of recent media attention, including a PBS documentary and a Time magazine report. End-of-life concerns, however, remain uncomfortable topics of discussion for many patients and physicians in the U.S. health care system.
In a new analysis appearing in the September 27 issue of the Journal of the American Medical Association, U.S. Department of Veterans Affairs (VA) researchers suggest that end-of-life conversations should be a routine and structured part of care that helps critically ill patients die according to their own values and wishes.
They also call for additional measures, including development of a new health care role emphasizing advanced illness care, and physician training and community awareness programs to help doctors, patients and caregivers with end-of-life discussions.
"We need to train all health care practitioners in standard communication models for conversations at the end of life," said lead author Daniel R. Tobin, M.D., of the VA Health Care Network Upstate New York, Albany Division. "I am proud to be a part of the VA’s national leadership that is improving care at the end of life for all Americans."
In their JAMA review, Dr. Tobin and co-author Dale G. Larson, Ph.D., of Santa Clara University, noted recent studies show patients hospitals should place more emphasis on palliative care, patient preferences for life-sustaining treatments, and referrals for hospice or home care.
Tobin and Larson also found a combination of barriers (both personal and institutional), which make it difficult for meaningful end-of-life conversations to occur in a health care setting. First, some patients with an advanced illness avoid end-of-life conversations to conceal their pain and feelings of self-blame, anger, loss or fear.
Next, physicians may avoid end-of-life conversations due to the following: fear of causing pain and bearing bad news to patients and their families, unfamiliarity with advance directive laws, their view that death is an enemy to be defeated, anticipation of disagreements with the patient, medical or legal concerns, or feeling threatened by such discussions in general.
Finally, barriers are caused by the health care system in general. End-of-life discussions are not a routine part of care for health care providers. Physicians are not compensated for psychosocial conversations, including end-of-life discussions. In addition, patients may receive treatment at a variety of health care delivery sites, where responsibility for end-of-life discussions is not clear.
The authors offer several strategies for improving the quantity and quality of end-of-life conversations, including improving communication skills training for physicians and other health care providers, adopting a patient-centered model of care, increasing focus on remaining quality of life activities, and developing programs to support end-of-life discussions earlier in the health care process.
The authors believe the development of a new health care professional, working under a physician’s direction, could effectively orchestrate and document end-of-life conversations. In fact, the VA Health Care Network Upstate New York, Albany Division, has such a model program.
"The exciting thing about our program is that we introduced the new role of an advanced illness care coordinator who works in collaboration with the patient, family, and physician to secure dignity and control in the last years of life," said Tobin.
In conclusion, the authors recommend randomized trials to examine new approaches and models for enhancing end-of-life conversations.
"I’m very pleased that VA is directly addressing this important and challenging matter," said Thomas Garthwaite, M.D., VA Undersecretary for Health. "All health care systems should be looking for better ways to help patients and their families deal with end-of-life issues."
This work was supported by the VA Health Care Network Upstate New York, Albany Division.
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